Assessment of Ohio’s Enhanced Primary Care Home Initiative

Assessment of Ohio's Enhanced Primary Care Home Initiative

Sharon K Hull, MD, MPH1 Shannon Ginther, JD2

Dushka Crane-Ross, PhD3 Denise Kropp4

Ohio Colleges of Medicine

Government Resource Center

1. Professor, Family and Community Medicine, Northeast Ohio Medical University; Director, Community-Based Health Services Research, Austen BioInnovation Institute in Akron 2. Policy Development and Implementation Specialist, Ohio Colleges of Medicine Government Resource Center 3. Director, University Relations, Ohio Colleges of Medicine Government Resource Center

4. Project Manager, Family and Community Medicine, Northeast Ohio Medical University

Table of Contents

Acknowledgements........................................................................................................................4 Introduction....................................................................................................................................5 Key Informants...............................................................................................................................6 Background.....................................................................................................................................7 Methods...........................................................................................................................................9 Projects..........................................................................................................................................10 Existing Projects...........................................................................................................................10 Aligning Forces for Quality ? Cincinnati ()...................10 Better Health, Greater Cleveland ().........................10 Access HealthColumbus ()......................................11 Emerging Projects........................................................................................................................11 Interview Findings and Results..................................................................................................12 Scope of Practice Engagement (See Table 1)............................................................................12 Payer Engagement (See Table 1).................................................................................................12 Outcome Measures ? Planned and Active................................................................................12 Key Successes.................................................................................................................................13 Key Challenges..............................................................................................................................13 Burnout and Staff Turnover..........................................................................................................13 High-Volume Medicaid Practices..............................................................................................14 Behavioral Health Integration.....................................................................................................14 Utilization of Health Care Teams..................................................................................................14 College and University Involvement in EPCH Initiative.........................................................14 Best Practices and Advice for Those Considering Practice Transformation........................15 Discussion.....................................................................................................................................17 Next Steps......................................................................................................................................19 Conclusions.............................................................................................................20 Table 1 ? Project Summary Table...............................................................................................21 Appendix 1 ? Semi-Structured Interview Questions.............................................................23 Appendix 2 ? Aggregated, De-Identified Interview Responses...............................................26 Scope of Practice Engagement...................................................................................................26 Payer Engagement? Successes and Challenges.........................................................................26 Outcome Measures ? Planned and Active...............................................................................27 Key Successes and Best Practices...............................................................................................28 Key Challenges..............................................................................................................................28

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Insight for Practices Considering Implementation of EPCH..............................................29 Burnout and Staff Turnover....................................................................................................30 High-Volume Medicaid Practices...........................................................................................31 Payer Mix Among Practices.................................................................................................31 Behavioral Health Integration.....................................................................................................32 Utilization of Health Care Teams..............................................................................................32 College and University Involvement in EPCH Initiative..................................................33 Perceptions of Cost-Benefit to Engaging in EPCH Initiative..................................33 Other Issues...................................................................................................................................34 References....................................................................................................................35

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Acknowledgements

The authors would like to acknowledge the support of Cyndi Dubbert, Administrative Assistant, in managing logistics and providing invaluable staff support to this project. The work of Janine E. Janosky, Ph.D., as consultant and reader is greatly appreciated. This project was funded by the State of Ohio through the Ohio Colleges of Medicine Government Resource Center. The project was completed with the support of the following institutions:

? Northeast Ohio Medical University (Formerly Northeastern Ohio Universities Colleges of Medicine and Pharmacy)

? Austen BioInnovation Institute in Akron

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Introduction

Ohio's Enhanced Primary Care Homes represent an evolutionary step, building on the classic model of a PatientCentered Medical Home (PCMH).1 Defined as "an enhanced model of primary care in which care teams attend to the multifaceted needs of patients, providing whole person comprehensive and coordinated patient-centered care," 2 Ohio's Enhanced Primary Care Home (EPCH) model differs from the classic PCMH model. Specifically, it includes the potential for a primary care home to be led by an advance-practice nurse, incorporates behavioral health into the model, and includes team-based care as a foundational goal.

PCMH efforts in Ohio began in earnest in 2007, with the Cleveland and Columbus projects; these were followed by efforts in Cincinnati that began in 2009. The Cleveland and Cincinnati projects are associated with the Robert Wood Johnson "Aligning Forces for Quality (AF4Q)" initiative (. jsp). This ongoing initiative focuses on practice recruitment and engagement to transform to the PCMH model of practice, with certification by the National Committee for Quality Assurance (NCQA) as Level 1, 2 or 3 PCMH Practices () listed as one measure of success for practices within these project sites.

In 2009, the Health Care Coverage and Quality Council (HCCQC) embarked on the development of a statewide medical home initiative, pulling together a steering committee to oversee the initiative's development and implementation. In addition, in 2010, Ohio House Bill 198 (HB198) established the "Enhanced Primary Care Home Education Pilot Project," designed to support selection of up to 44 primary care practices affiliated with select medical or nursing schools in the state. The law also supported efforts to reform the curriculum in medical and nursing schools to effectively prepare the health professions workforce to function in medical home practices and to pioneer efforts to disseminate this model of care into the state's practice environment. Funds from the HCCQC were used, in part, to support practice transformation and expansion efforts in existing projects in Cincinnati, Columbus, and Cleveland, as well as to support the site selection process for projects under HB198. During the period covered by this report, the HB198 Education Advisory Group, with support from the four emerging projects, successfully selected 44 practice sites (37 physician-led and 7 nurse-led) to participate in this work.

The practice consulting firm, TransforMED (), assisted in developing and implementing a selection process for choosing among candidate sites for the emerging projects. TransforMED also assisted some, though not all, of the existing projects with a structured transformational process of PCMH model adoption. The Ohio Academy of Family Physicians (OAFP) served as administrative coordinator for the funding and oversight of the HB198 efforts to create the emerging projects.

This assessment relies on key informant interviews with project leaders and key personnel involved in seven EPCH projects in Ohio, at OAFP and TransforMED. Written project status reports from each of the projects were reviewed and findings included in this report. Funding was provided for the EPCH initiative by the HCCQC from November, 2010 ? June, 2011. The assessment covers project efforts during that period and is designed to identify best practices, key challenges and next steps for advancing the Enhanced Primary Care Home effort in Ohio as state policymakers and stakeholders proceed to implement key provisions of federal health reform legislation (Patient Protection and Affordable Care Act or ACA).

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